976 Canadian Family Physician

Le Mdecin de famille canadien

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VOL 58: SEPTEMBER SEPTEMBRE 2012
Top 10 Forgotten Diagnostic Procedures
Wood lamp examination
David Ponka MD CM CCFP(EM) FCFP Faisal Baddar MD CM CCFP
Contraindications
None. Cover patients eyes to prevent injury to the retina
or conjunctiva.
Applications
Diagnosis of numerous dermatologic disorders as well
as porphyrias.
Equipment necessary
Wood lamp.
Set-up
This procedure works best in a completely dark
environment, so turn off lights and close any window
shades in the room. Allow the Wood lamp to warm up
(about 1 minute), and give your eyes time to adapt to
the dark.
1

Procedure
Shine the light directly above the lesion or sample in
question. Carefully inspect the area, paying close atten-
tion to zones in uorescence and their borders. Watch
out for lint, topical medications, and soap residue! They
all uoresce, creating false positives, usually red-pink.
2

Thankfully, they can generally be removed.
Evidence
While no epidemiologic evidence is currently available,
physiologic evidence is well established. A Wood lamp
is a mercury arc covered by a Wood lter, which allows
a narrow range of light to escape: 320 to 400 nm.
2
The
2 main substances that uoresce are dermal collagen
and porphyrins.
Diagnostic confrmation
Pigment disorders: biopsy.
Bacterial infections: culture.
Fungal infections: potassium hydroxide microscopy,
culture.
2
Porphyrias: urine testing for porphobilinogen and
5-aminolevulinic acid, genetic testing.
3
Pigment disorders
1,3
Hypopigmentation or depigmentation. Lesions demon-
strate increased sharpness of borders under Wood lamp
examination and fluoresce bright blue-white owing to the
increased amount of dermal collagen illuminated. This
results from decreased or absent intervening melanin.
Vitiligo: patches, varying in location and extent.
Tuberous sclerosis: patches; characteristic shapes
are lanceolate or ash-leaf. Other far-less-specific
shapes exist.
Hypomelanosis of Ito: whirled or streaked patterns.
Hyperpigmentation. Lesions demonstrate enhanced
border contrast under Wood lamp examination owing
to increased absorption of light by increased amounts
of melanin.
Melasma. If of epidermal origin, lesions are well demar-
cated. Dermal melasma demonstrates less colour contrast.
Infections
1,2,4
Bacterial
Pseudomonas species: green in folliculitis and
infected burn wounds.
Corynebacterium minutissimum: coral red in ery-
thrasma.
Propionibacterium acnes: orange-red in comedones.
Fungal
Tinea versicolor: Malassezia furfur yellowish-white or
copper-orange.
Pityrosporum folliculitis: Bluish-white in a follicular
pattern.
Tinea capitis: Fluoresces in less than 5% of cases in
the United States; blue-green (most Microsporum spe-
cies), occasionally dull yellow (Microsporum gypseum)
and dull blue (Trichophyton schoenleinii).
Porphyrias
1,4
These disorders all cause red-pink fluorescence.
However, subtypes vary by which samples fluoresce:
red blood cells, urine, teeth, gallstones, or feces.
Dr Ponka is Associate Professor in the Department of Family Medicine at the
University of Ottawa in Ontario. Dr Baddar is a staff hospitalist at Pembroke
Regional Hospital and a community preceptor in the Department of Family
Medicine at the University of Ottawa.
References
1. Asawanonda P, Taylor CR. Woods light in dermatology. Int J Dermatol
1999;38(11):801-7.
2. Andrews MD, Burns M. Common tinea infections in children. Am Fam Physician
2008;77(10):1415-20.
3. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet 2012;375(9718):924-37.
4. Ducharme EE, Silverberg NB. Selected applications of technology in the pediatric
dermatology ofce. Semin Cutan Med Surg 2008;27(1):94-100.
The physical examination is facing extinction in modern
medicine. The Top 10 Forgotten Diagnostic Procedures
series was developed as a teaching tool for residents
in family medicine to reaffrm the most important
examination-based diagnostic procedures, once commonly
used in everyday practice. For a complete pdf of the Top 10
Forgotten Diagnostic Procedures, go to http://dl.dropbox.
com/u/24988253/bookpreview%5B1%5D.pdf.